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213: Association of Dietary Phosphorus to Protein Ratio With Mortality in Hemodialysis Patients
NKF 2010 Spring Clinical Meetings Abstracts
213
215
ASSOCIATION OF DIETARY PHOSPHORUS TO PROTEIN RATIO WITH MORTALITY IN HEMODIALYSIS PATIENTS Nazanin Noori, Kamyar Kalantar-Zadeh, Csaba P Kovesdy, Rachelle Bross; Debbie Benner, Joel D Kopple. Harold Simmons Center, Harbor-UCLA, Torrance; VA Salem; DaVita, El Segundo, CA. Epidemiologic studies show an association between higher predialysis serum phosphorus (P) and death risk in maintenance hemodialysis (MHD) patients (pts). There are little data about the effects of the ratio of dietary P to protein (P/P) on outcomes. We examined 5yeqar (2001-06) survival predictability of dietary P/P ratio, estimated from the Block’s food frequency questionnaires, at the start of a cohort of 224 MHD pts. The P/P ratio was divided in 4 increments: <12, 12 to <14 (reference), 14 to <16 & >=16 mg/g. We adjusted for: (1) casemix, sevelamer or calcium- binders & residual urine; (2) dietary energy, protein & K; (3) Malnutrition inflammation complex syndrome (MICS), EPO & vitamin D doses, nPCR, & BMI; & (4) inflammatory markers (CRP, IL-6, TNFα). MHD pts in the highest P/P group (>16 mg/g) exhibited almost 2-times increased death risk (see Figure):
All cause death hazard ratio
5
4
A85
U n a d ju s te d C a s e -m ix a d ju s te d C a s e -m ix + d ie t+ s e ru m p h o s p h o ru s a d ju s te d C a s e -m ix + d ie t+ M IC S + in fla m m a tio n a d ju s te d
3
SPONTANEOUS KIDNEY RUPTURE IN PREGNANCY DUE TO COCAINE INTOXICATION Chike Nzerue , Mary Fleming, Sandra Torrente, Glenfield Knight, Marquetta Faulkner. Dept of Medicine, Obstetrics & Radiolgy, Meharry Medical College, Nashville, TN, USA. Spontaneous Kidney rupture is rare in pregnancy. Cocaine has Multoiple toxic effects on the kidney. We report a case of spontneous rupture of the kidney pregnancy due to cocaine abuse. A 36-year-old-woman at 18 weeks gestation presented to ED with sudden right flank abdominal pain unassociated with trauma, fever, dysuria nor frequency. She had a BP of 165/95, a hemoglobin of 6.7g/dL, BUN of 6mg/dl & creatinine of 1.0mg/dL. CT scan and renal US showed large right perinephric hematoma with positive urine drug screen for cocaine. She was transfused 4 units of blood, and conservatively managed due to pregnancy and absence of active bleeding on Doppler US. The patient left hospital against medical advice after 4 days, but returned again at 29 weeks gestation with ARF, preeclampsia, cocaine intoxication and intrauterine fetal demise. A cesarean section was done, and repeat Us showed reduction of in size of subcapsular hematoma. Kidney rupture has benn previously reported in a male cocaine user. Our case shows that cocaine use can cause kidney rupture, ARF and preeclampsia in pregnancy.
2
Reference 1
0 <12 1 2 -< 1 4 1 4 -< 1 6 >=16 D ie ta ry P h o s p h o ru s to P ro te in R a tio (m g /g )
Hence, higher dietary P/P ratio is associated with increased death risk in MHD pts, even after adjustments for serum P, type of P-binder & dietary protein, energy & K intake.
214 SODIUM THIOSULFATE: A NOVEL AND EFFECTIVE TREATMENT FOR CALCIPHYLAXIS Lama Noureddine, Megan Landis, Nina Patel, Sharon Moe, Division of Nephrology, Indiana University, Indianapolis, Indiana. Calciphylaxis, also known as calcific uremic arteriolopathy (CUA), is a rare condition with dismal prognosis and high mortality rate that mainly affects patients (pts) with ESRD. CUA is characterized by soft tissue calcification and skin ulceration due to calcium deposition in subcutaneous vessels. Case reports in the literature have described successful treatment of CUA with sodium thiosulfate (ST) but these are subject to reporting bias. ST acts as a chelator of calcium from the vessel walls and as an antioxidant to improve endothelial dysfunction. To determine whether ST is an effective treatment for calciphylaxis, we identified all pts ( n = 14) who received ST for CUA between 4/1/03 to 1/1/08 by pharmacy records, and then performed a retrospective review of electronic medical records and/or information from the primary Nephrologist. The primary end point was the number of pts who responded to ST with improvement of lesion stage graded as 1 to5 (pain, livido reticularis, erythema, central necrosis, and eschar, respectively). CUA risk factors were also assessed. Our results demonstrated that 14 patients received ST. The patients were 49 ± 12 years old, on dialysis 4.5 ± 4.2 yrs, 4 male and 10 female, 4 White and 10 African American. The average (SD) phosphorus, calcium and PTH at the time of ST were 5.6 ± 2.8 mg/dl, 8.3 ± 0.6 mg/dl, 458 ± 909 pg/ml and 3 were on coumadin. The most advanced stage of lesion at the time of ST was pain in 2, livido in 3, erythema in 5, necrosis in 1, and eschar in 3 Overall, 35% (5/14) improved lesion stage, 14% (2/14) did not improve lesion stage, and 14 % (2/24) had a cessation in the progression of lesions. However, the pts who did not improve were advanced in their stage (3 or greater) of disease, were on HD for longer periods of time and received fewer doses of ST. Overall, there was a 53.8% mortality rate (7/13 died, status of one pt unknown), all presenting in stage 3 or greater. The average stage of those who died at the start of ST was 3.7, compared to 2.8 in those who survived. We conclude that ST is an effective treatment for calciphylaxis if given in the early stages of disease and for a consistent period of time. Thus, early clinical detection and aggressive intervention are imperative to prevent mortality from this deadly disease.
216 UNIQUE ETIOLOGY OF HYPERCALCEMIA IN MALE TO FEMALE TRANSGENDER PATIENTS Onyema Ogbuagu, Peter Soltani, Kayode Lawrence, Aaron Stern. Mount Sinai School of Medicine (Elmhurst), Elmhurst, NY, USA. Male to female transgender individuals use a variety of silicone products and estrogen to produce a more feminine appearance. We postulate a unique etiology of hypercalcemia in 2 male to female transgender patients with puzzling symptomatic hypercalcemia. Our first patient is a 38 yr old Hispanic phenotypic female referred to renal clinic for recurrent symptomatic hypercalcemia. She presented with a distant history of bilateral silicone breast implants; and multiple free silicone injections into her lips, hips and breasts, long standing hypercalcemia complicated with recurrent urolithiasis and renal failure from resulting obstructive uropathy. She was on estrogen tablets. Exam revealed multiple firm, non tender nodular swellings at sites of prior silicone injections. Labs showed hypercalcemia (14mg/dl), hyperphosphatemia (4.8mg/dl), hypercalciuria (379.6mg/24hr), elevated Cr (3.1mg/dl), low 25-OH Vit D (13ng/ml), high normal 1,25OH Vit D (51ng/ml), low normal PTH assay (18.0pg/ml). PTH-RP, SPEP, CXR, parathyroid nuclear scan, bone scan were unremarkable. The second patient is a 48 yr old Hispanic male to female transgender who presented with recurrent urolithiasis and worsening renal failure secondary to hypercalcemia. She had numerous free silicone injections into her hips, face and breasts 8 years prior to presentation that resulted in clinically appreciable injection granulomas. She took estrogen tablets as part of her feminizing regimen. Labs showed hypercalcemia (11.8mg/dl), hypercalciuria (637mg/24 hr), low 25-OH Vit D (9ng/ml), high normal 1,25-OH Vit D (63ng/ml), low PTH (1pg/ml). PTH-RP, SPEP and UPEP were unremarkable. Both patients had hypercalcemia secondary to elaboration of 1,25-OH Vit D by silicone induced granulomas likely exacerbated by estrogen use. Silicone, once considered innocuous, has been reported to cause granulomas that leads to an unregulated extra-renal production of 1,25OH Vit D resulting in hypercalcemia. Estrogen has been reported to increase calcium absorption by increasing 1,25-OH Vit D. We highlight the combined effect of silicone induced granulomas and estrogen causing hypercalcemia in this unique patient population.
213
215
ASSOCIATION OF DIETARY PHOSPHORUS TO PROTEIN RATIO WITH MORTALITY IN HEMODIALYSIS PATIENTS Nazanin Noori, Kamyar Kalantar-Zadeh, Csaba P Kovesdy, Rachelle Bross; Debbie Benner, Joel D Kopple. Harold Simmons Center, Harbor-UCLA, Torrance; VA Salem; DaVita, El Segundo, CA. Epidemiologic studies show an association between higher predialysis serum phosphorus (P) and death risk in maintenance hemodialysis (MHD) patients (pts). There are little data about the effects of the ratio of dietary P to protein (P/P) on outcomes. We examined 5yeqar (2001-06) survival predictability of dietary P/P ratio, estimated from the Block’s food frequency questionnaires, at the start of a cohort of 224 MHD pts. The P/P ratio was divided in 4 increments: <12, 12 to <14 (reference), 14 to <16 & >=16 mg/g. We adjusted for: (1) casemix, sevelamer or calcium- binders & residual urine; (2) dietary energy, protein & K; (3) Malnutrition inflammation complex syndrome (MICS), EPO & vitamin D doses, nPCR, & BMI; & (4) inflammatory markers (CRP, IL-6, TNFα). MHD pts in the highest P/P group (>16 mg/g) exhibited almost 2-times increased death risk (see Figure):
All cause death hazard ratio
5
4
A85
U n a d ju s te d C a s e -m ix a d ju s te d C a s e -m ix + d ie t+ s e ru m p h o s p h o ru s a d ju s te d C a s e -m ix + d ie t+ M IC S + in fla m m a tio n a d ju s te d
3
SPONTANEOUS KIDNEY RUPTURE IN PREGNANCY DUE TO COCAINE INTOXICATION Chike Nzerue , Mary Fleming, Sandra Torrente, Glenfield Knight, Marquetta Faulkner. Dept of Medicine, Obstetrics & Radiolgy, Meharry Medical College, Nashville, TN, USA. Spontaneous Kidney rupture is rare in pregnancy. Cocaine has Multoiple toxic effects on the kidney. We report a case of spontneous rupture of the kidney pregnancy due to cocaine abuse. A 36-year-old-woman at 18 weeks gestation presented to ED with sudden right flank abdominal pain unassociated with trauma, fever, dysuria nor frequency. She had a BP of 165/95, a hemoglobin of 6.7g/dL, BUN of 6mg/dl & creatinine of 1.0mg/dL. CT scan and renal US showed large right perinephric hematoma with positive urine drug screen for cocaine. She was transfused 4 units of blood, and conservatively managed due to pregnancy and absence of active bleeding on Doppler US. The patient left hospital against medical advice after 4 days, but returned again at 29 weeks gestation with ARF, preeclampsia, cocaine intoxication and intrauterine fetal demise. A cesarean section was done, and repeat Us showed reduction of in size of subcapsular hematoma. Kidney rupture has benn previously reported in a male cocaine user. Our case shows that cocaine use can cause kidney rupture, ARF and preeclampsia in pregnancy.
2
Reference 1
0 <12 1 2 -< 1 4 1 4 -< 1 6 >=16 D ie ta ry P h o s p h o ru s to P ro te in R a tio (m g /g )
Hence, higher dietary P/P ratio is associated with increased death risk in MHD pts, even after adjustments for serum P, type of P-binder & dietary protein, energy & K intake.
214 SODIUM THIOSULFATE: A NOVEL AND EFFECTIVE TREATMENT FOR CALCIPHYLAXIS Lama Noureddine, Megan Landis, Nina Patel, Sharon Moe, Division of Nephrology, Indiana University, Indianapolis, Indiana. Calciphylaxis, also known as calcific uremic arteriolopathy (CUA), is a rare condition with dismal prognosis and high mortality rate that mainly affects patients (pts) with ESRD. CUA is characterized by soft tissue calcification and skin ulceration due to calcium deposition in subcutaneous vessels. Case reports in the literature have described successful treatment of CUA with sodium thiosulfate (ST) but these are subject to reporting bias. ST acts as a chelator of calcium from the vessel walls and as an antioxidant to improve endothelial dysfunction. To determine whether ST is an effective treatment for calciphylaxis, we identified all pts ( n = 14) who received ST for CUA between 4/1/03 to 1/1/08 by pharmacy records, and then performed a retrospective review of electronic medical records and/or information from the primary Nephrologist. The primary end point was the number of pts who responded to ST with improvement of lesion stage graded as 1 to5 (pain, livido reticularis, erythema, central necrosis, and eschar, respectively). CUA risk factors were also assessed. Our results demonstrated that 14 patients received ST. The patients were 49 ± 12 years old, on dialysis 4.5 ± 4.2 yrs, 4 male and 10 female, 4 White and 10 African American. The average (SD) phosphorus, calcium and PTH at the time of ST were 5.6 ± 2.8 mg/dl, 8.3 ± 0.6 mg/dl, 458 ± 909 pg/ml and 3 were on coumadin. The most advanced stage of lesion at the time of ST was pain in 2, livido in 3, erythema in 5, necrosis in 1, and eschar in 3 Overall, 35% (5/14) improved lesion stage, 14% (2/14) did not improve lesion stage, and 14 % (2/24) had a cessation in the progression of lesions. However, the pts who did not improve were advanced in their stage (3 or greater) of disease, were on HD for longer periods of time and received fewer doses of ST. Overall, there was a 53.8% mortality rate (7/13 died, status of one pt unknown), all presenting in stage 3 or greater. The average stage of those who died at the start of ST was 3.7, compared to 2.8 in those who survived. We conclude that ST is an effective treatment for calciphylaxis if given in the early stages of disease and for a consistent period of time. Thus, early clinical detection and aggressive intervention are imperative to prevent mortality from this deadly disease.
216 UNIQUE ETIOLOGY OF HYPERCALCEMIA IN MALE TO FEMALE TRANSGENDER PATIENTS Onyema Ogbuagu, Peter Soltani, Kayode Lawrence, Aaron Stern. Mount Sinai School of Medicine (Elmhurst), Elmhurst, NY, USA. Male to female transgender individuals use a variety of silicone products and estrogen to produce a more feminine appearance. We postulate a unique etiology of hypercalcemia in 2 male to female transgender patients with puzzling symptomatic hypercalcemia. Our first patient is a 38 yr old Hispanic phenotypic female referred to renal clinic for recurrent symptomatic hypercalcemia. She presented with a distant history of bilateral silicone breast implants; and multiple free silicone injections into her lips, hips and breasts, long standing hypercalcemia complicated with recurrent urolithiasis and renal failure from resulting obstructive uropathy. She was on estrogen tablets. Exam revealed multiple firm, non tender nodular swellings at sites of prior silicone injections. Labs showed hypercalcemia (14mg/dl), hyperphosphatemia (4.8mg/dl), hypercalciuria (379.6mg/24hr), elevated Cr (3.1mg/dl), low 25-OH Vit D (13ng/ml), high normal 1,25OH Vit D (51ng/ml), low normal PTH assay (18.0pg/ml). PTH-RP, SPEP, CXR, parathyroid nuclear scan, bone scan were unremarkable. The second patient is a 48 yr old Hispanic male to female transgender who presented with recurrent urolithiasis and worsening renal failure secondary to hypercalcemia. She had numerous free silicone injections into her hips, face and breasts 8 years prior to presentation that resulted in clinically appreciable injection granulomas. She took estrogen tablets as part of her feminizing regimen. Labs showed hypercalcemia (11.8mg/dl), hypercalciuria (637mg/24 hr), low 25-OH Vit D (9ng/ml), high normal 1,25-OH Vit D (63ng/ml), low PTH (1pg/ml). PTH-RP, SPEP and UPEP were unremarkable. Both patients had hypercalcemia secondary to elaboration of 1,25-OH Vit D by silicone induced granulomas likely exacerbated by estrogen use. Silicone, once considered innocuous, has been reported to cause granulomas that leads to an unregulated extra-renal production of 1,25OH Vit D resulting in hypercalcemia. Estrogen has been reported to increase calcium absorption by increasing 1,25-OH Vit D. We highlight the combined effect of silicone induced granulomas and estrogen causing hypercalcemia in this unique patient population.